COMMUNITY HEALTH WORK IN SUB-SAHARAN AFRICA: The Kenyan experience

The role of CHWs in sub-Saharan Africa has evolved over time and place in response to changing health care priorities, disease burdens, and shortages of human resources for health. CHW programmes play a crucial role in the support and delivery of services in sub-Saharan Africa and are critical in efforts to tackle the existing health worker crisis. However, they need support, supervision and financial and non-financial incentives if they are to carry out their work effectively. This session will look at how one such CHW programme in a South Kenyan district at the foot of Mt.Kilimanjaro informs the above issues.

Presented by: Dr. Edwin Lutomia Mangala MSc. Public health-health promotion student Leeds Metropolitan University.

Objectives

• To analyse, through a practical example, the role of CHWs in

public health in Sub-Saharan Africa

• To identify some of the key challenges that face CHW programs

• To explore possible solutions to identified challenges

ScopeBackground information

◦ Social, political, economic◦The healthcare system

The CHW program in Loitokitok district◦Design and implementation◦Early challenges and intervening

measures◦Successes and failures◦Key issues arising

BackgroundSub-Saharan Africa & Kenya

Country Profile • Geography• 580,367sq.km• Capital – Nairobi• Other cities – Mombasa, Kisumu

• People• Population – 39m• Religion – Christian 82.6%, Muslim

11.2%, Traditional 5%• Languages

• Official – English, Swahili• Others – 40 from Bantu (67%),

Nilotic (30%) and cushitic (3%)• Government

• President• Prime Minister

• Economy• Largest in Eastern Africa• Services – 59.5%• Agriculture – 23.8%• Industry and commerce – 16.7%

• Political• Multiparty state in 1992• New constitution 2010• Over 40 political parties

Kenya health care systemMinistry of Health

◦Ministry of Medical Services◦Ministry of Public Health and Sanitation

Two broad divisions◦Public (government owned)◦Private

Kenya Healthcare systemTraditional pyramidal structure

◦Dispensaries and private clinics◦Health centres◦Sub-district hospitals and nursing

homes◦District hospitals and private

hospitals◦Provincial hospitals (8)◦National hospitals (2)

Important InstitutionsMedical practitioners and dentists boardClinical officers councilNursing council of KenyaKenya medical supplies agency (KEMSA)Pharmacy and Poisons BoardNational hospital insurance fund (NHIF)Kenya Medical Research Institute (KEMRI)

Source: WHO (2009)

• Budgetary allocation to health fell from 7% (2009/2010) to 6.5%; Target 15%

Kenya

Africa

UK Global

Total population (millions) 39 61, 565

Population living in urban areas (%) 22 38 90 50

Gross national per capita (PPP int. $) 1,570 2,561 35,860 10,599

Life expectancy at birth (years) 60 54 80 68

Adult mortality rate (per 1,000 adults 15 – 59 years) 319 383 77 176

Under 5 mortality rate (1,000 live births) 84 127 5 60

Maternal mortality ratio (per 100,000 live births 530 620 12 260

HIV prevalence rate % ( adults 15-49) 6.3 4.7 0.2 8.0

Literacy rate (%) 73 62 99

Source: WHO (2009)

Some key health/Development Indicators

Healthcare workersSpecialist doctorsMedical OfficersClinical OfficersNursesPublic Health Officers

Major causes of morbidityHIV/AIDSTuberculosisMalariaPneumoniaRespiratory tract infectionsRoad accidentsFactory accidentsGastroenteritisDiabetes mellitus

Key IssuesA largely rural and poor

population that has limited access to the formal healthcare system

Inadequate expenditure on health

No universal health financing scheme

Limited health workers; mostly urban based

CHW program in Loitokitok district

LocationKuku Group ranch – 1,500 sq.km

◦ Semi-arid◦ Average Temp- 30 0 Celsius

12,000 inhabitants - Maasai Community◦ Nomadic herders◦ Traditional

Implementing agencies/Institutions

• Ministry of public health and sanitation• Maasai Trust• Christian Children’s Fund• African Medical Research Foundation (AMREF)

Health workersPublic health Officer (1)Medical Officer (1)Nurses (6)Support staff (10)

StructureCHW selection by communityTraining (3 months)Allocation

◦1CHW per 2-3 homesteads (20-30 households)

◦Duties – Water, sanitation, ITNs, Immunization, Antenatal care, Delivery, nutrition, communicable diseases, health education

◦Resources – Bicycle, CHW bag, Stationery

Reporting/supervision◦Monthly to health centre

Early challengesToo much workload for CHWsMotivationFailure to translate theory into

practice ? literacyLarge coverage area

Emergency measuresReduce number of CHWsNarrow focusCloser supervisionIncentives

Notable successesIncreased immunization coverageHome management of diarrhoea

using Oral Rehydration SaltsSurveillance system

FailuresWater and SanitationReproductive healthITNs

Key IssuesResource limited setting

◦Does it increase access?◦Does it address health workers

shortage?Cost-effectiveness

◦Is it really cheap?Empowering

◦Who decides?◦Who acts?

How is success evaluated

Excerpts from Kenya budget 2011/2012

• £10m – Recruitment of 3,150 nurses and 1,050 public health officers for rural areas

• £2.7m – 1,050 motorcycles and 2,100 CHWs in rural areas

Solutions?